Provider Demographics
NPI:1770511529
Name:GORDON, PRISCILLA (CRNA)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:1000 N VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1000
Practice Address - Country:US
Practice Address - Phone:516-705-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY440251367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered